Eyeworld Supplements

5 Precision and stability: How I achieve the best results for my patients By Johnny Gayton, MD I 'm a big proponent of the femtosecond laser, but the ORA SYSTEM has improved our accuracy and our outcomes even more than the femto has. By mar- rying the two, we have more accurate refractive outcomes, and that improved accuracy has decreased our enhance- ment rate. Cost benefit Some surgeons have been reluctant to incorporate the ORA SYSTEM into their prac- tices for several reasons. One concern for some surgeons is the cost of in- corporating the system into their practice. However, we have found that our pa- tients are very interested in the technology being a part of their procedure, so it has significantly increased our revenue, thus taking care of the cost issue for us. Anoth- er concern is the increased time needed for the proce- dure. There is no question that there is some increase in time when adding the ORA SYSTEM to your prac- tice, but the profit margin is generally greater for a cata- ract procedure with special testing than it is for a more routine cataract surgery. This means that we are compensated for the extra time. Additionally, having a less-than-satisfactory refractive result takes up a lot of time in the office and because I get more accurate results in cataract proce- dures with the ORA SYSTEM, I have fewer enhancements later on that cost us both time and money. Some surgeons may also remem- ber a time when previous versions of the ORA SYSTEM were not as accurate as it is now. Over the years, this technology has had sever- al upgrades, and to date has over 700,000 cases in the AnalyzOR database, so its accuracy has improved greatly from earlier ver- sions. Because I was so convinced of the value of this technology, I decided to jump in with both feet and had a system placed in both operating rooms. Driven by outcomes To achieve the best possible outcomes, I believe the first step is to set realistic ex- pectations with my patients regarding their treatment options and anticipated outcomes. Additionally, I think it's important to get as much information as possible in the pre-op plan- ning stage. We use several different topographies, Ks, a refraction with our auto- mated system, sometimes even a manual refraction might be used. I also think it's very important to look at patients' glasses, and of course we use the ORA SYSTEM. Unrivaled stability Another factor that has an impact on outcomes is the IOL that is chosen. Alcon has long been known for the rotational stability of its AcrySof toric IOLs 1,2 . Between the design of the AcySof IQ Toric Stableforce haptics, which hold the lens in place, and the AcrySof IQ material which promotes adhesion through fibronec- tin binding, the lens is not likely to rotate 3 . This stabil- ity certainly results in con- sistent outcomes. I have long been a propo- nent of using a toric IOL in people who have irregular astigmatism, if we could refract their astigmatism and they were not contact lens dependent. In these patients, we have had great results with the ORA SYS- TEM. We always have to use caution in implanting toric IOLs in patients who have had corneal transplants, previous RK, and various eye injuries. With the ORA SYSTEM, I have success- fully implanted toric IOLs in these more challenging patient types. I believe that I would have missed the refractive target in some of these patients, if I had not had the ORA SYSTEM. Recently, I used the ORA SYSTEM to reposition a lens for a patient that I had previously missed her refractive target prior to acquiring the ORA SYSTEM. Her best-corrected vision improved two lines. But more importantly, her un- corrected vision improved from 20/200 to 20/50. It was a huge improvement. As it turns out we were original- ly 20° off target, the ORA SYSTEM definitely helped us with that case. A few years ago, Dr. Warren Hill said that there is a huge tsunami of people who have had refractive surgery headed toward cataract surgeons. That tsunami is here. Every surgery day, I see RK patients who have been evaluated, and we have pulled a lens based on their pre-op surgical plan. Then, in the OR the ORA SYSTEM recommends a different lens power. In every case, we have gone with the ORA SYSTEM recommendation, and we have not been dis- appointed. In a case that my associate recently per- formed, the ORA SYSTEM recommended 2.5 diop- ters more lens power than predicted, they followed the recommendation, prevent- ed a refractive surprise and the patient ended up with the intended result. While I don't think the ORA SYSTEM has improved my confidence utilizing a toric IOL, it has improved my confidence in being more accurate with them. For ex- ample, I recently implanted some T9s and being off axis even a little bit with these high-powered toric IOLs has a significant impact on outcomes. When using the ORA SYSTEM, we have been right on target with these lenses. n References 1. Potvin R, et al. Toric intraocular lens orientation and residual refractive astigmatism: an analysis. Clin Ophthalmol. 2016;10:1829-1836. 2. Visser N, Bauer NJ, Nuijts RM. Toric intraocular lenses: historical overview, patient selection, IOL calculation, surgical techniques, clinical outcomes, and complications. J Cataract Refract Surg. 2013;39(4):624-637. 3. Linnola RJ, Sund M, Ylonen R, et al. Adhesion of soluble fibronectin, laminin, collagen type IV to intraocular lens materials. J Cataract Refract Surg. 1999;1486-1491. Please see Important Product Information about the products in this article on pages 3 and 7.

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